Healthcare Provider Details

I. General information

NPI: 1174566905
Provider Name (Legal Business Name): COMMUNITY SUPPORT PROFESSIONALS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 WELLINGTON AVE UNITC
WILMINGTON NC
28401-7704
US

IV. Provider business mailing address

1606 WELLINGTON AVE UNITC
WILMINGTON NC
28401-7704
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-4505
  • Fax: 910-799-4345
Mailing address:
  • Phone: 910-799-4505
  • Fax: 910-799-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number8300728H
License Number StateNC

VIII. Authorized Official

Name: CHARLES CHRISTOPHER CREECH
Title or Position: CEO
Credential:
Phone: 910-799-4505